Poorly executed care transitions as patients move from one delivery setting to another lead to fragmented care evidenced by duplication of services, inappropriate and conflicting recommendations, medication errors, and patient confusion and distress. The lack of timely transfer of essential clinical information is a major barrier to effective care transitions. Three large Minnesota-based integrated health care delivery systems have come together to plan the use of information technology to enhance communication at care transitions, an activity crucial to the well-being of the 100 million Americans with chronic illness and a rapidly growing population of elderly. The long-term objective is to enable more informed clinical decisions that should result in safer and higher quality care of patients involved in care transitions. The partners will develop an implementation plan for a community- and patient-shared electronic medical record abstract designed to enhance the care and safety of those crossing delivery sites. This abstract will be available near the point of care, be that location internal or external to the participating systems. Using a federated information model, the abstract will be a composite derived from the records of each partner that holds pertinent information such as a problem list, medications, allergies, baseline physical, physiologic, and cognitive function, advance directives, and supplemented by recent prescription claims history. Our specific aims are to assemble expert planning and advisory groups, define the abstract's content, clinical presentation, workflow integration, and mode of access and delivery, specify an open standard for contributions to the abstract and for the abstract itself, develop an organizational and technical plan for processing federated clinical data into a complete yet succinct and readily used abstract, and determine relevant measures that are feasible and reflective of anticipated care and safety improvements. These teams will complete a comprehensive implementation plan at the end of a 12-month planning period that is consistent with each partner's goals and capacity. [unreadable] [unreadable]